Today, Angelina Jolie gracefully walked the public through her decision to pursue the second portion of her preventative surgery, the removal of both of her ovaries and fallopian tubes. To spark your memory, Angelina carries a specific genetic mutation termed BRCA1, which puts her at higher risk than the general population for certain cancers—namely breast and ovarian.
You may recall her first New York Times Op-Ed in which she described her family history of cancer, her struggle with preventative surgery, and the genetic lottery. While there is no doubt that her words touched thousands of people, the question continues to remain—is her course of action generalizable, or applicable to the general public?
Let’s begin with her first surgery. Back in May of 2014, we discussed the role of preventative double mastectomy procedures and the evidence surrounding its effectiveness. Angelina’s most recent surgery is called a risk-reducing bilateral salpingo-oophorectomy, or the removal of ovaries and fallopian tubes on both sides.
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This procedure was completed via laparoscopic technique, which means instead of one big incision that exposes the entire lower pelvis for surgical removal, multiple smaller incisions are used in combination with cameras to remove the targeted elements. This is a serious surgery. There are major blood vessels, urinary structures, and neuronal elements all within this small space and the complications can be severe.
Generally, a hysterectomy (removal of the uterus) is not performed at the same time unless there is a specific indication for it. For example, patients with lynch syndrome carry a higher risk of endometrial cancer and thus may elect to undergo the larger, more invasive procedure. Angelina points out that this was not part of her plan, and from what her medical history suggests, an appropriate decision.
Risk-reducing bilateral salpingo-oophorectomy is primarily reserved for women at the highest risk of developing two specific types of cancer: epithelial ovarian and fallopian tubal cancer. To give you an idea, and as Angelina discusses, the lifetime risk of ovarian cancer is 35-45 percent in women with BRCA1 gene mutations as compared to 1.5 percent in the general population. As the waters begin to clear, there is some concern that cancer can develop in either the fallopian tube or the ovary, thus the indication to each element on both sides.
How effective is the procedure in reducing cancer risk? Some studies suggest that the relative risk of ovarian/fallopian tubal/peritoneal cancer after the risk reducing surgery in patients with BRCA1 is as low as 0.04. That is to say that in carriers of BRCA mutations, a risk-reducing surgery is associated with an 80 percent reduction in ovarian cancer, though the benefit of risk-reducing surgery decreases with advancing age.
There are a number of studies out there, and it appears the general consensus is that this surgery will reduce the risk of cancer in the appropriately selected patient. And some studies have even showed that in premenopausal women with BRCA mutations the risk-reduction surgery significantly reduced the risk of breast cancer as well. It is important to remember that even if patients undergo the risk-reduction surgery, they still have a possibility of developing “ovarian-like” cancers in the peritoneum.
What are the downsides? Well, the definitive effects of this procedure are sterility and surgical menopause. As Angelina discusses, patients must engage in a very personal and detailed conversation with their physicians regarding changes the body will experience, the need for specific hormone replacement therapies, and family planning. Keep in mind, Angelina is only 39 and must deal with the onset of menopause. We are talking about hot flashes, sleep disturbance, mood changes, hair and skin changes.
Patients may also experience changes in their sexual health and even osteoporosis. Surgical menopause is very different from physiologic or normal menopause in the sense that surgery is abrupt and definitive, whereas normal menopause is gradual, giving the body time to adjust.
There are alternatives to a risk-reduction surgery. As in any decision-making tree, one can choose to do nothing, hoping that such a diagnosis never crosses one’s path. One may also choose a less invasive treatment modality, such as early detection and screening via routine focused clinical examinations or chemo-prevention via birth control.
The decision-making algorithm is not straightforward. Every single patient must be evaluated on an individual basis, to discuss her wishes, concerns and risks. Angelina’s very public discourse is valuable, potentially initiating a higher level of preventative care and concern in America’s women.
Prevention is always the right medicine, however such high-risk procedures and preventative therapies will only provide relief in the appropriately selected patient. One of the best things we can do for American medicine is educate, get the discussion going, and get people thinking.
